Provider Demographics
NPI:1447319330
Name:MCKEVITT, MARY LOUISE (ARNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LOUISE
Last Name:MCKEVITT
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:LOUISE
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4361 TALBOT ROAD SOUTH
Mailing Address - Street 2:SUITE #112
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-6226
Mailing Address - Country:US
Mailing Address - Phone:425-255-5111
Mailing Address - Fax:425-254-0984
Practice Address - Street 1:4361 TALBOT RD S
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-6226
Practice Address - Country:US
Practice Address - Phone:425-255-5111
Practice Address - Fax:425-254-0985
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00037524163W00000X
WAAP30004306363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB34551Medicare ID - Type Unspecified
WAS58802Medicare UPIN